Eptinezumab-jjmr (Vyepti®)
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
POLICY
I. INDICATIONS
The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.
FDA-Approved Indication
Vyepti is indicated for the preventive treatment of migraine in adults.
II. CRITERIA FOR INITIAL APPROVAL
Preventive treatment of migraines
Authorization of 6 months may be granted for preventive treatment of migraines for members 18 years of age or older when either of the following criteria are met:
A. Member has chronic migraine headache defined as 15 to 26 headache days per month, of which at least 8 are migraine days
B. Member has episodic migraine headaches defined as 4 to 14 headache days per month, of which at least 4 are migraine days
III. CONTINUATION OF THERAPY
All members (including new members) requesting authorization for continuation of therapy must be currently receiving therapy with the requested agent.
Authorization for 12 months may be granted when all of the following criteria are met:
A. The member is currently receiving therapy with Vyepti
B. Vyepti is being used to treat an indication enumerated in Section II
C. The member is receiving benefit from therapy. Benefit is defined as a reduction in migraine days per month from baseline
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.
ADDITIONAL INFORMATION
For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).
REFERENCES
1. Vyepti [package insert]. Bothell, WA: Lundbeck Seattle BioPharmaceuticals, Inc.; October 2022.
2. Ailani J., Burch RC, Robbins MS. The American Headache Society Consensus Statement: Update on Integrating New Migraine Treatments into Clinical Practice. Headache. 2021 Jul;61(7):1021-1039
ORIGINAL EFFECTIVE DATE: 6/2/2020
MOST RECENT REVIEW DATE: 5/14/2024
ID_CHS
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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